physician self-audit: a scoping review

Literature Review

Physician Self-Audit: A Scoping Review

ANNA R. GAGLIARDI, PHD; MELISSA C. BROUWERS, PHD; ANTONIO FINELLI, MD; CRAIG E. CAMPBELL, MD;BERNARD A. MARLOW, MD; IVAN L. SILVER, MD, MED

Introduction: Self-audit involves self-collection of personal performance data, reflection on gaps between perfor-mance and standards, and development and implementation of learning or quality improvement plans by individualcare providers. It appears to stimulate learning and quality improvement, but few physicians engage in self-audit.The purpose of this study was to identify how self-audit has been operationalized; factors influencing self-auditconduct and outcomes, including program design; and issues warranting further research.

Methods: A systematic review of quantitative and qualitative studies was undertaken. Two individuals independentlyreviewed searches of indexed literature databases, tables of contents, and references of eligible studies. Data wereextracted and tabulated to describe the nature and impact of self-audit programs.

Results: Six studies evaluated the impact of self-audit programs. No program was based on a model or theorythat informed its design. All studies showed improved compliance with care delivery guidelines and/or improvedpatient outcomes, although these findings were largely self-reported. Programs varied so features associated withbenefit could not be identified.

Discussion: Overall there is a need for guidance on all aspects of self-audit for both participants and leaders.This guidance would be useful to educators, professional associations, and medical certification bodies to plan,develop, implement, evaluate, and support self-audit programs. Further research should aim at developing trainingprograms and tools that address and evaluate a variety of competencies across different disciplines using morerigorous research designs, including both quantitative and qualitative approaches.

Key Words: self-assessment, self-audit, continuing education, systematic review

Disclosures: The authors report none.

Dr. Gagliardi: CIHR New Investigator in Knowledge Translation, AssociateProfessor, University of Toronto, Departments of Surgery and Health Pol-icy, Management and Evaluation, and Institute of Medical Science, AffiliateScientist, Toronto General Research Institute and Co-Chair, Minimal Risk,University Health Network Research Ethics Board; Dr. Brouwers: Direc-tor, Program in Evidence Based Care, Cancer Care Ontario, Lead, CapacityEnhancement Program, Canadian Partnership Against Cancer, AssociateProfessor and Lead, Health Services Research, Department of Oncologyand Associate Member, Department of Clinical Epidemiology & Biostatis-tics, McMaster University; Dr. Finelli: Urologic Oncologist, Princess Mar-garet Hospital, University Health Network, Assistant Professor, Universityof Toronto, Department of Surgery; Dr. Campbell: Director, ProfessionalAffairs, Royal College of Physicians and Surgeons of Canada; Dr. Marlow:Director, Continuing Professional Development, College of Family Physi-cians of Canada; Dr. Silver: Vice Dean, Continuing Education and Profes-sional Development, Faculty of Medicine, University of Toronto, Professor,University of Toronto, Department of Psychiatry.

Correspondence: Anna R. Gagliardi, Toronto General Hospital, 200 Eliza-beth Street, Toronto, Ontario, Canada M5G 2C4; e-mail: [email protected].

C© 2011 The Alliance for Continuing Medical Education, the Society forAcademic Continuing Medical Education, and the Council on ContinuingMedical Education, Association for Hospital Medical Education.� Published online in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/chp.20138

Introduction

A recent systematic review found an inverse relationship be-tween the number of years physicians practice and their lev-els of factual knowledge, compliance with standards of care,and quality of patient outcomes.1 Lifelong learning amongpracticing physicians is therefore crucial to the routine de-livery of high-quality patient care. Educational or qualityimprovement strategies delivered by external sources havehad minimal or inconsistent impact.2−6 To improve healthservice delivery and associated patient care outcomes, novelstrategies are needed to facilitate routine continuing profes-sional development.

Adult education theory suggests that learning is mostlikely to take place when professionals are involved in mon-itoring their own performance (eg, through an audit of pastclinical performance using chart review or reflection on caredelivery experiences). Comparing one’s past performanceagainst a criterion such as a clinical practice guideline orlocal practice standard may confirm current practice, triggercognitive dissonance, or create awareness that knowledgeor skill may be lacking.7 Theoretically, awareness of sucha gap would prompt professionals to identify their learningneeds, plan and engage in appropriate learning activities,8

and modify their practice.

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Self-Audit Scoping Review

To be successful, this learning process rests heav-ily on professionals’ capacity for self-assessment, a prac-tice endorsed by medical certification bodies worldwide.9

Self-assessment is currently conceptualized as an activity in-volving reflection on and evaluation of gaps between one’sperformance and a benchmark, often in the form of guidelinerecommendations or clinical standards.10 Self-assessment isseen as an important avenue to quality in clinical practice;it is, for example, routinely practiced by family physiciansconsidered high performing by their peers.11 Yet it is unclearwhether physicians can accurately self-assess. A systematicreview found that self- and external evaluations of perfor-mance were not congruent in 13 of 20 comparisons.12 How-ever, self-assessment may have greater potency. A 5-yearlongitudinal study of the influence of multisource feedbackon physician self-assessment found that factors such as pro-fessionalism and clinical competence were stronger determi-nants of self-ratings compared with external feedback, high-lighting the value of reviewing one’s own performance.13

Thus, there remains an imperative to examine how self-assessment can be improved and supported.

Self-audit extends the concept of self-assessment. Whilethere is no universally accepted definition, self-audit is of-ten understood as the process by which physicians reviewclinical data obtained through chart reviews or other means,compare the data with a standard or benchmark to identifygaps, decide which gaps warrant action, establish learninggoals, undertake learning activities, and apply new knowl-edge or skill into practice.14 Self-audit may be distinguishedfrom audit and feedback, where externally generated per-formance data are provided to target stakeholders with nomechanism to prompt reflection and action—a limitation ofthe audit and feedback approach.3,15 Because it makes useof clinical data, self-audit has the potential to produce moreobjective and therefore more accurate assessments of one’scurrent practice.

There is some evidence that self-audit can be an effec-tive strategy for facilitating practice change. An analysis ofstimuli associated with 8576 learning episodes recorded by652 Canadian physicians found evidence, consistent withthe tenets of adult learning, that physicians were more likelyto have changed their practice as a result of self-audit thanother stimuli such as reading the medical literature or groupmeetings.14 In a previous study, we provided general sur-geons with a paper-based self-audit tool.16 This consistedof a single page divided into several sections with checkbox options. For individual cases where optimal manage-ment was uncertain, the tool was meant to prompt reviewof patient indication and characteristics, nature of the un-certainty, learning sources consulted to address uncertainty,findings, and application of the findings. We analyzed dic-tated accounts of learning episodes based on the self-audittool and interviewed participants to understand how theyhad used it. Fifteen participants submitted 115 cases over 2months. Learning needs were identified in 66.7% of casesand led to modifications in intended care plans for 34.2%

of cases, highlighting the potential impact of self-audit toolsalone. Interviewed participants said that the self-audit toolprompted them to spend more time considering managementoptions and led to better, more confident decisions. However,it appears that few physicians engage in self-audit. In 2006,only 3.8% of all credits submitted by Fellows to the RoyalCollege of Physicians and Surgeons of Canada Maintenanceof Certification program were based on self-audit.17 Similarfindings have been reported elsewhere, although we do notknow the extent to which self-audit may be conducted but notformally reported.18 Several barriers to self-audit have beenidentified, including perceptions that it was onerous, limitedtime, lack of guidance and leadership, and inability to accesspersonalized performance data.21−26

In terms of guidance for performing a self-audit, our pre-liminary review of the literature identified 3 resources. Oneis a brief article describing 5 steps in the self-audit cycle,including defining criteria and standards in the domain beingexamined, measuring current performance in an objectiveway, comparing performance against criteria and standards,identifying the need for change, and making any requiredchanges followed by reaudit.19 The second is a 6-page ar-ticle based on the consensus of a working group of Cana-dian physicians that advocated for evidence-based practicein surgery.20 It provides a brief overview on how to identifya topic and associated benchmarks, collect and analyze chartdata to compare one’s practice with standards, and reflectupon practice changes that may be necessary. The third is a206-page manual produced by the National Institute for Clin-ical Excellence in the United Kingdom. It identifies similarstages in the self-audit process, but describes them in greaterdetail and provides corresponding tools and templates.18

To summarize, self-audit is supported by educational the-ory, encouraged by medical certification bodies, and appearsto stimulate the identification of opportunities for learningand quality improvement, intent to change practice, and ac-tual practice improvements.7−9,14,16 However, the conceptand process remain poorly defined, so further knowledge isneeded to understand how to support physician self-audit.We need a better understanding of how self-audit shouldbe structured for different goals, physicians, and services toachieve optimal benefit. The purpose of this research wasto review the literature examining the conduct and impactof self-audit to identify how self-audit has been operational-ized, factors influencing the conduct and impact of self-auditincluding self-audit program design, and issues warrantingfurther research.

Methods

Approach

A scoping review was conducted. This approach is appropri-ate for topics not previously reviewed and where literaturemay be sparse.27 Comparable in rigor to a systematic review,its purpose is to identify whether sufficient evidence exists to

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—31(4), 2011 259DOI: 10.1002/chp

Gagliardi et al.

conduct a systematic review, synthesize available evidenceto begin describing a particular concept or phenomenon, andgenerate research questions where gaps in knowledge arerevealed. While much could be gained from exploring theconcept of self-audit as it is employed in the literature acrossmultiple disciplines, as a start, this review focused on themedical literature to establish a baseline picture of whetherand how self-audit has been applied in the health care sec-tor. For the purposes of this review, self-audit was definedas a process undertaken by individual physicians involvingself-collection of performance data; comparison with stan-dards, benchmarks, or guidelines to identify and reflect ongaps; decision making about which gaps warrant action; anddevelopment and implementation of a learning or qualityimprovement plan.

Data Collection

An information specialist (ARG) searched MEDLINE, EM-BASE, and the University of Toronto Research and Develop-ment Resource Base (www.rdrb.utoronto.ca) for items pub-lished from 1990 to October 2010 using database-specificindexing terms considered most relevant to the concept ofself-audit: clinical/medical audit or practice assessment, andcontinuing education or guideline adherence or programmedinstruction or learning. Eligible articles included quantitativestudies (meta-analyses, surveys, observational studies, ran-domized trials) and qualitative studies (reviews/conceptualanalyses, interviews, focus groups) published in English-language peer-reviewed journals that evaluated self-auditprograms to describe factors influencing either use or out-comes associated with use. Studies were ineligible if theyfocused on the clinical effectiveness of medical interven-

tions; solely involved provision of externally generated per-formance data (ie, audit and feedback) without some elementof self-evaluation; or were in the form of abstracts, letters,or editorials. Database searches were augmented by an ex-amination of 5 years of online tables of contents for theJournal of Continuing Education in the Health Professions,Academic Medicine, and Advances in Health Science Educa-tion: Theory and Practice, which were most likely to publishresearch related to the continuing professional developmentof physicians according to our preliminary searches. We alsosearched the references of all eligible studies.

Data Analysis and Conceptual Framework

To systematically and comprehensively extract data from allrelevant studies in any type of literature review it is useful todevelop a data extraction form based on elements includedin a model or theory that reflects the concept of interest.There is no single model or theory that describes self-auditor associated influencing factors, so we drew upon multi-ple sources to assemble a conceptual framework to guidedata extraction and analysis. It included design components(tools or mechanisms provided to assist with data collec-tion, analysis, and evaluation), competence assessed (sinceself-audit is meant to evaluate some aspect of knowledge orperformance), influencing factors, and outcomes (TABLE 1).To develop a list of components of self-audit programs, wedrew on Finucane’s analysis of maintenance of competenceprograms worldwide, which identified various types of tools(tests, questionnaires, chart review, case study, peer inter-action) that could be used as part of self-audit programs.28

For a typology of competencies, we used Epstein’s dimen-sions of professional competence, which were based on his

TABLE 1. Conceptual Framework of Self-Audit Tool/Program Features and Outcomes

Dimension Definition/Example

Components Tests, questionnaires, chart review, case study, peer/colleague interaction

Competence Cognitive (knowledge, management, problem-solving, information searching, critical appraisal)

Technical (physical examination, surgical, procedural)

Integrative (judgment, reasoning, linking tacit and explicit knowledge, managing uncertainty)

Relationship (communication, handling conflict, teamwork, teaching others)

Affective/moral (tolerance of anxiety, emotional intelligence, respect for patients/peers, caring)

Habits of mind (observation of thinking, curiosity, recognition of biases, willingness to change)

Influencing factors Internal (years in practice, attitude of openness, mindfulness of alternatives)

External (data availability, professional culture)

Outcomes Satisfaction with process

Learning new knowledge, skill or practice

Change in practice or utilization of a new practice

Patient outcomes (satisfaction, behavior, health)

260 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—31(4), 2011DOI: 10.1002/chp


systematic review of the literature.29 These included a to-tal of 33 competencies in 6 categories (cognitive, technical,integrative, relationship, affective/moral, and habit of mind)that could be the basis of a self-audit program. Our back-ground literature review yielded several internal and externalfactors (years in practice, attitude, data availability, profes-sional culture) that can influence the conduct and outcomesof self-audit.30−32 For impact, we adopted the potential out-comes of learning identified by Overeem: satisfaction withthe process; learning about a new competence; a change in,or adoption of, a new competence; and patient or healthoutcomes.33 Although these elements served as a guide, ourdata collection was not limited to them if other pertinentdetails were identified.

Data were initially extracted and tabulated by the prin-cipal investigator (ARG), then independently reviewed by aresearch assistant. The two met to discuss and resolve differ-ences when independently extracted data were discrepant orunclear. Tabulated findings were examined to discuss studydetails, including design, participants, setting, and clinicalissue being evaluated. The nature and impact of availableself-audit programs or tools was described in terms of theconceptual framework (components, competence assessed,influencing factors, and outcomes).

Results

Studies Evaluating Self-Audit Programs

Search Results. The search of indexed databases and tablesof contents identified 506 unique results. A review of titlesand abstracts excluded 433 citations that did not focus onself-audit or involved audit by external parties only, ratherthan self-audit. The remaining 73 potentially eligible articleswere retrieved. Upon review of full-text articles, 63 wereexcluded because they did not evaluate self-audit programs,leaving 10 articles for inclusion in the study.

In scoping reviews, study quality is often used to rejectstudies not meeting certain criteria. Since we found only afew studies, we included them all. In addition, many method-ologic details of the studies were vague or missing, so wedid not formally assess and report on study quality using astandardized tool. Instead, we described study design andself-audit program design to inform discussion of limitationsin this body of knowledge that should be addressed throughongoing research.

Conduct and Outcomes of Self-Audit. Six observational stud-ies evaluated self-audit conduct or outcomes among a rangeof 14 to 966 general practitioners conducting self-audit onreflux disease, diabetes, or cardiovascular management.34−39

A table summarizing the studies included in this review canbe accessed in the online version of this article (see “Support-ing Information” section at end of article). Two studies alsoincluded specialists. Five of 6 studies reported the number ofpatients audited by each participant, which ranged from 10 to

40 cases. Four studies noted the self-audit completion rate,which ranged from 48% to 80%. Competencies evaluatedincluded cognitive and technical skills. Two studies assessedand identified learning about gaps in practice. All studiesassessed and identified the implementation of changes topractice. No studies objectively assessed patient outcomes asa result of process improvements that were implemented.

Program Features Potentially Associated With Outcomes.Program features are summarized in TABLE 2. In all cases,data were self-collected by individual participants using printor computerized forms provided by the coordinating agency,submitted to the coordinating agency for analysis, and re-turned to individuals for review. Three studies involved asingle self-audit, and 3 studies included a follow-up self-audit after individuals received the results of their initial self-audit. In 4 studies, these data were returned to participantswith comparative peer data. All initiatives involved some el-ement of education to prepare participants for undertakingself-audit, or some mechanism to prompt reflection in addi-tion to data collection and review. Reflection prompts tookthe form of a pre- or postaudit survey, regional workshop,facilitator visit, and selection of tailored change strategy viaan automated system.

Additional Studies Exploring Factors Influencing Conductand Outcomes of Self-Audit

Four additional studies examined self-audit participant viewsand barriers influencing the completion or impact of self-audit. Among 87 of 115 Australian general practitioners sur-veyed about their self-audit experience, 78% were satisfiedwith the preaudit evening workshop that taught them theprocess of self-audit, and 85% strongly agreed that the pro-cess had a positive effect on reflective learning.40 A surveyof 3 health authorities in the United Kingdom responsiblefor 327 practices with over 1150 general practitioners foundthat 169 practices had participated in a diabetes managementaudit. Participation was associated with larger and more de-veloped practices, particularly those in less socioeconomi-cally deprived areas, and having a physician interested indiabetes.41 A survey of consultants and senior registrars inthe Greater Glasgow Health Board reported that 72% hadsome experience with self-audit, 47% were currently carry-ing out self-audit, and 40% were carrying out change as aresult of a self-audit.42 In terms of the process of self-audit,42% were very confident about identifying a subject for audit.However, they had little confidence in getting started (32%),collecting the data (25%), analyzing results (42%), apply-ing for funding (60%), using computers for audit (51%), andimplementing change (33%). Most respondents said that as-sistance in the form of a starter kit (62%) and training sessions(74%) would be useful. Interviews with 30 physicians desig-nated to lead and coordinate audit among trusts in the UnitedKingdom found that 7 were not aware they were audit lead, 3were given the role because no one else wanted it, and only 3


Gagliardi et al.

TABLE 2. Self-Audit Program Design

Participants Planning Data Collection Number Audits Feedback Process

Before- Audit Education or

Study Individual Group Self External Self∗ External Single After Individual Comparative Only Reflection

Duffy et al,

200834

+ – – + + + + – – + – +

Kirby et al,

200835

+ – – + + + – + – + – +

Holmboe

et al,

200636

+ – – + + + + – + – – +

Cutts,

200137

+ – – + + + + – – + – +

Rudd et al,

200138

– + – + + + – + – + – +

Mott et al,

199839

– + – + + + – + + – – +

Note: Self-collected data submitted to a central coordinating organization.

were aware of the existence of terms of reference.43 Twenty-one believed they were not fulfilling their role, primarily dueto lack of time, lack of influence over others, and lack ofcomputer infrastructure for collecting data. Thus, it appearsthat physician views about self-audit may be positive, buttraining, tools and guidance are needed.

Discussion

The purpose of this research was to review the literatureexamining the conduct and impact of self-audit to identifyhow self-audit was operationalized, factors influencing theconduct and impact of self-audit including self-audit pro-gram design, and issues warranting further research. Fewstudies were identified that delivered and evaluated self-audit programs. While all studies reported positive results,including improved compliance with care delivery guide-lines and/or patient outcomes, there was a high degree ofvariation in program content, format, delivery, and compe-tencies assessed, so program features associated with ben-eficial outcomes could not be identified. Few measures ofconduct and outcomes were employed, and most outcomeswere evaluated based on self-report. None of the programswere designed around an explicit framework or model, andnone used qualitative methods to explore factors that mayhave influenced conduct and outcomes. However, it is no-table that all programs involved features that may have stim-ulated learning and practice changes including pre-/postaudit

surveys, regional workshops, facilitator visits, comparativedata, follow-up audit, and provision of action plans. Four ad-ditional studies explored factors influencing self-audit andfound that larger practices, particularly those featuring aphysician in the role of a leader who advocated and/or guidedself-audit, may be more likely to undertake self-audit. Over-all, there is a need to develop guidance for both participantsand leaders on all aspects of self-audit, including tools andtraining.

There are several limitations to our study. We may not haveidentified all studies that evaluated the impact of self-audit.In part, this may be due to the fact that the concept of self-audit is not uniformly labeled or described in the literatureand all relevant studies may not have been retrieved, despiteour systematic search of the medical literature. We did nothave the resources to review the nonmedical literature or theplethora of professional society Web sites such as the Ameri-can Board of Internal Medicine (www.abim.org/moc/earning-points.aspx) for information about their self-audit programsand tools. In the future a search of other bodies of knowledgeand sources of information may yield additional informationthat facilitates the development of effective self-audit toolsand programs.

This review, conducted using a scoping approach aimedat describing the available literature on this topic, suggestsavenues for further practice and research. Self-audit may bea valuable form of self-regulated learning activity for con-tinuing professional development; it appears to have poten-tial to lead to learning and actual practice improvements.



Lessons for Practice

• Six observational studies evaluated the im-pact of self-audit on care delivery andoutcomes.

• None of the self-audit programs were basedon an explicit model or theory that informedtheir design.

• Three self-audit how-to guides were identi-fied by literature search.

• There is a need for guidance on all aspectsof self-audit for both participants and lead-ers, including tools and training.

• Self-audit may stimulate learning and qual-ity improvement; further research usingmixed quantitative and qualitative ap-proaches is needed to more rigorously eval-uate the impact of self-audit programs onclinical practice and patient outcomes andidentify optimal strategies for supportingself-audit.

These findings lend support to ongoing efforts by healthprofessional educators, professional associations, medicalcertification bodies, and individual health care providers toplan, develop, implement, evaluate, and support self-auditprograms.

That we identified few studies evaluating self-audit clearlyindicates further research is needed. Exploratory studies maybe required prior to developing, implementing, and evalu-ating self-audit programs. These would involve qualitativeconsultations with different types of physicians to better un-derstand their needs and preferences for self-audit support,which could then be incorporated into self-audit program de-sign. This might be followed by pilot studies in which self-audit program components that support different self-audittasks (data collection, data analysis, comparison with stan-dards, reflection on gaps, planning of learning, and qualityimprovement) are varied to understand their potential impacton self-audit conduct and outcomes. At this stage, self-auditprogram designers could consider evaluating different com-petencies, tools or mechanisms, and outcomes, as suggestedby the conceptual framework used as the basis for our dataanalysis. Such developmental work would identify the mostpromising supports for self-audit in different clinical andprofessional contexts before thorough testing with more rig-orous quantitative research design coupled with qualitativeevaluation to fully understand impact and how different de-sign elements and other factors contributed to impact. Furtherresearch might also identify who is providing self-audit sup-port and the infrastructure required to do so, and evaluate the

effectiveness of those programs. This may include specialtysocieties and universities or agencies that offer continuingprofessional development.

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Supporting InformationAdditional Supporting Information may be found in the

online version of this article:TABLE S1. Studies Evaluating Self-Audit Design and

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physician self-audit: a scoping review

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